1. PHYSIOLOGICAL CHANGEGS OF PREGNANCY AHMED ABDULWAHAB

2.  Maternal physiologic adjustment to pregnancy are designed to support the requirements of fetal needs without affecting maternal well-being.  The normal values of several hematologic, biochemical, and physiologic indices during pregnancy differ markedly from those in the non pregnant range and also according to duration of pregnancy.

3.  ALIMENTARY TRACT.  Appetite is usually normal without changes  Pica. Dietary craving or aversion for non nutritional substances.  Mouth, ptyalism usually associated with nausea of pregnancy.  Dentition, gum become soft and edemtous.

4.  STOMACH.  Tone and motility decreases because of the effect the PROGESTERONE hormone and emptying time of the stomach is prolonged  Gastro esophageal junction sphincter tone decreases leading to heart burns  Gastric acid secretion decreases and peptic ulcer disease decreases.

5.  Small bowel motility decrease and increases iron absorption.  Colon, there is decrease motility resulting in constipation,increase water and sodium absorption and dilatation of hemorrohdial veins.  Liver  Signs of normal pregnancy that may mimic liver disease

6.  Spider angiomata and palmer erythema due to increase estrogen level.  Decrease albumin and increase alkaline phosphatase.  Nausea and vomiting usually in first trimester

7.  Respiratory system.  Mechanical changes.  Subcostal angles transverse chest diameter, and chest circumference increases and the diaphragm level is pushed up.  Lung volume and pulmonary function.  Tidal volume increase inspiratory capacity increases, vital capacity decreases

8.  Skin.  Vascular changes, due to estrogen.  Spider angiomata,palmer erythema.  Striae gravidarum  Pigmentation changes,increases melanocyte- stimulating hormones.  Darkening of nipples, areolae,umbilicus, axillae, perineum and linea nigra

9.  Chloasma or mask of pregnancy.  Pigmented navi.  Abdominal wall there is separation of the recti muscles

10.  Urinary system.  Anatomic changes.  Kidneys increase in both length and weight.  Renal pelvis increase resulting in physiological hydro nephrosis.  Ureters dilate starts by 8 weeks gestation.  Right ureter is larger than the left causing hydroureter and urinary stasis.

11.  Dilatation is commonly above the pelvic brim.  Consequences.  Increase risk of pyelonephritis and asymptomatic bacteriuria  Renal function tests.  Renal plasma flow, glomerular filtration rate and creatinine clearance are all increase more than 50%,  Blood urea creatinine and uric acid all decrease

12.  Glucosuria is common in normal pregnancy and has no correlation with blood sugar level.  Aminoaciduria.  Increase excretion of water soluble vitamin folate and vitamin B 12

13.  Cardiovascular system.  There is a change in the position of the heart.  Normal changes in heart sound include.  Exaggerated splitting of S1  Gallop pulse in 90% of normal pregnancy  Systolic ejection murmur.  Mammary souffle

14.  EKG is unchanged except for left axis deviation.  Increase cardiac output by 40% due to increase in both stroke volume and heart rate.  Cardiac output depends on maternal position,it is lowest when in supine position. Supine hypotension syndrome.

15.  Blood pressure.  There is a progressive decrease in both systolic and diastolic pressure, after 24 weeks the pressure gradually increase and return to non pregnant level by term.  Central venous pressure remain unchanged.

16.  Hematological changes.  Plasma volume increase 50% by term it begins by 10 weeks and plateaus at 30 weeks gestation there is more increase in multiple pregnancy or larger fetuses.  Red blood cell increases by 30% at term.  Physiological anemia result because the plasma volume increases more than RBC.

17.  Leukocyte and platelets.  White blood cell mostly PMN granulocytes increases progressively in pregnancy.  Platelets slightly decrease.  Coagulation system.  Pregnancy is a hyper coagulable state.  Fibrinogen increase by 50%.  Factors V11,V111,1X,and X all increases

18.  Iron metabolism.  Absorption depends on pregnancy state and bone marrow iron stores,40% absorption in the iron deficient state.  The total iron requirement is 1000 mg and the daily requirement is 3.5 mg.  Maternal iron deficiency does not affect fetal iron stores because of active iron transport across the placenta.

19.  Endocrine and metabolic changes.  Thyroid gland.it increase in size.  Thyroid binding globulin increases as a result of estrogen stimulation of the liver.  The active unbound form remain unchanged or slightly decrease.  The following thyroid hormones do not cross the placenta T3, T4,and TSH, thyroid immunoglobulins crosses the placenta as well ass anti thyroid medication 

20.  Adrenal gland.  Total and free cortisol increase by two fold  Aldosterone secretion is markedly increase.  Deoxycortisone level increases.  Pancreas there hypertrophy and hyperplasia.  Fasting blood glucose is lower than in non pregnant state